TRICARE Claims Instructions

The Claims Instructions page assists providers with submitting claims and making claims inquiries.

Claims Submission

Electronic claim submission is required for TRICARE network providers and encouraged for non-network providers.

NOTE: Network providers in Alaska are not required to submit claims electronically.

You can submit via one of the options below.

• Submit Electronically: Use Payer ID 99726.
  • XPressClaim – A secure, full-service online claims submission tool.
    Please Note: XPressClaim is not a batch claims system. It is a one-claim-at-a-time product and works best for providers who need to submit 150 claims or less per month.
  • Claims clearinghouse – A third-party organization that acts as a middleman between health care providers and insurance companies, or other payers, to process medical claims electronically.
  • Availity’s Basic Clearinghouse – The TriWest self-service, secure provider portal.
• Submit Paper Claims:
  • Scan paper claim into an electronic format legibly and appropriately. When filing paper claims, you must use one of the following:
    • A CMS 1500 form (for professional charges).
    • A CMS UB-04 form (for institutional charges).
  • Include all required information to prevent delays in processing:
    • Completed Claim Form: Fill out all sections of the claim form accurately.
    • Supporting Documentation: Attach any necessary documentation, such as itemized bills or medical records.
    • Provider Information: Include your provider information, such as name, address, and National Provider Identifier (NPI).
  • Mail to TRICARE West Claims, P.O. Box 202160, Florence, SC 29502-2160.

Benefits of Using Availity Essentials

Register on Availity to:

• Enroll in EDI claims submission. Electronic submission is encouraged!
• Check claim status.
• View/print a TRICARE Remittance Advice.
• Enroll in Electronic Funds Transfer and/or Electronic Remittance Advice.

Reconsiderations and Appeals

Providers can submit a claim review request for reconsideration when they need to dispute the outcome of a processed claim.

Examples of issues that may need secondary review include:

• Allowed amount disputes.
• Other health insurance issues.
• Timely filing denials.
• Penalties for no authorization.
• Denial code(s).

Download the Provider Claims Reconsideration form and mail or fax to the address below. Please include all supporting documentation relevant to the review request. A claim reconsideration must be submitted no later than 90 days from the date of the remittance.

TRICARE West Correspondence
P.O. Box 2748
Virginia Beach, VA 23450
Fax: 1-866-852-1969

There are a few issues that are appealable:

• Claims denied due to TRICARE policy limitations.
• Claims denied as not medically necessary.
• Claims processed as POS only when the reason for dispute is that the service was for emergency care.

Only the following individuals may file an appeal:

• The beneficiary (including minors).
• The parent or guardian representing a minor or beneficiary.
• The non-network participating provider of services.
• A representative appointed by the proper appealing party (Must be in writing and be signed by the proper appealing party, or the representative must be court-appointed).

All appeal requests must be in writing and signed by the appealing party or the appealing party’s representative. The appeal request must state the issue in dispute. A copy of the initial denial (EOB/ provider remittance advice) and any additional documentation in support of the appeal should be submitted with the request. An appeal request must be received within 90 days of the date on the remittance advice.

Providers should mail or fax appeal requests to:

TRICARE West Claims Appeals
P.O. Box 2777
Virginia Beach, VA 23450
Fax: 1-866-670-4330

Overpayments and Refunds

To refund an overpayment, please submit the payment with supporting documentation to identify the overpaid claim to the address below.

TRICARE West Finance
P.O. Box 202162
Florence, SC 29502-2162

Timely Filing Waivers

According to TRICARE guidelines, providers must file claims within one year from the date of service or the discharge date for inpatient services. TRICARE denies claims received after the deadline.

A timely filing waiver can be requested by providing documentation that proves one of the following:

• Retroactive eligibility or authorization was issued after the filing deadline.
• The patient was mentally incompetent and did not have a legal guardian appointed.
• The claim was submitted before the filing deadline. (Note: Only claims that have been assigned a claim number can be appealed.)
• The Explanation of Benefits (EOB) from the patient’s other health insurance (OHI) was received within the TRICARE filing deadline, and the claim was submitted to TRICARE within 90 days from the date of the OHI decision.

Providers can send requests for a timely filing waiver to:

TRICARE West Correspondence
P.O. Box 2748
Virginia Beach, VA 23450